The map is not the territory: medical records and 21st century practice

Stephen A Martin & Christine A Sinsky
The Lancet
Published: 25 April 2016

Summary

Documentation of care is at risk of overtaking the delivery of care in terms of time, clinician focus, and perceived importance. The medical record as currently used for documentation contributes to increased cognitive workload, strained clinician–patient relationships, and burnout. We posit that a near verbatim transcript of the clinical encounter is neither feasible nor desirable, and that attempts to produce this exact recording are harmful to patients, clinicians, and the health system. In this Viewpoint, we focus on the alternative constructions of the medical record to bring them back to their primary purpose—to aid cognition, communicate, create a succinct account of care, and support longitudinal comprehensive care—thereby to support the building of relationships and medical decision making while decreasing workload.

Here are two excerpts:

While our vantage point is American, documentation guidelines are part of a global tapestry of what has been termed technogovernance, a bureaucratic model in which professionals' behaviour is shaped and manipulated by tight regulatory policies.

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In 1931, the scientist Alfred Korzybski introduced the phrase "the map is not the territory", to suggest that the representation of reality is not reality itself. In health care, creating the map (ie, the clinical record) can take on more importance and consume more resources than providing care itself. Indeed, more time may be spent documenting care than delivering care. In addition, fee-for-service payment arrangements pay for the map (the medical note), not the territory (the actual care). Readers of contemporary electronic notes, composed generously of auto-text output, copy forward text, and boiler plate statements for compliance, billing, and performance measurement understand all too well the gap between the map and the territory, and more profoundly, between what is done to patients in service of creating the map and what patients actually need.

Contemporary medical records are used for purposes that extend beyond supporting patient and caregiver. Records are used in quality evaluations, practitioner monitoring, practice certifications, billing justification, audit defence, disability determinations, health insurance risk assessments, legal actions, and research.

The article is here.

Texas: Doctoral Degree in Psychology Required for Independent Practice

Austin, TX ‐ Today, Judge Rhonda Hurley in Travis County District Court, Austin, Texas, upheld the ruling that the entry level to independent practice of psychology in Texas is the doctoral degree. Judge Hurley ruled that the Texas State Board of Examiners of Psychologists (TSBEP) has the authority to regulate the practice of Licensed Psychological Associates (LPAs) through its rule making authority which states only doctoral‐trained, Licensed Psychologists may practice independently.

In September, 2010 the organization which represents Licensed Psychological Associates, the Texas Association of Psychological Associates (TAPA), filed a lawsuit in Austin, Texas, against the TSBEP on the grounds that the Board has no statutory authority to prevent Licensed Psychological Associates from practicing independently. According to Texas statute, Licensed Psychological Associates are defined as individuals trained in psychology at the Master’s level. By Board Rule, LPAs must practice under the supervision of a doctoral‐trained Licensed Psychologist. The Texas Psychological Association (TPA) was granted permission by the court to intervene in this case; arguing the intention of the legislature was that only doctoral‐trained individuals could provide independent psychological services. TPA claimed that TSBEP rule, which clearly states the supervision requirement for LPAs, does define how psychology is to be practiced in this state even though the supervision requirement is void in the statute.

David White, TPA’s Executive Director, states “We thank Judge Hurley for her judgment in this case and for clarifying this issue that has been debated for so many years in the psychology community. We appreciate the services provided by Licensed Psychological Associates but are fully committed to assuring that independent psychological practice in Texas remains solely for individuals trained at the doctoral level.”